Severity of Pain: In general over the past month the intensity of my pain has been (check one)

MildModerateModerate-SevereSevere

Timing of pain: How often do you have your pain: (check one)

Constantly (100% of the time)Intermittently (30-60% of the time)Nearly Constantly (60-95% of the time)Occasionally (less than 30% of the time)

Pain / Symptom Quality: How would you describe your pain?: (please check all that apply)

Burning

Sharp

Cutting

Throbbing

Cramping

Dull/Aching

Pressure-like

Shooting

Others

If Others, Please describe:

Associated with pain, I feel the following:

Numbness

Pins and Needles

I have a weakness in my:

Upper Extremities

Lower Extremities

Dropping Objects

Falls

Lose of Bladder / Bowel Control

Other

If Lose of bladder or Bowel Control, Please explain?:

If Other, please specify:

Activities and your pain

Does your pain limit your ability to work?:

YesNo

How long can you sit?:

None

30 Minutes

1 Hour

> 2 Hours

How long can you stand?:

None

30 Minutes

1 Hour

> 2 Hours

To assist in walking, I use:

Cane

Walker

Wheelchair

No assistive devices

Are there activities that you are NOT able to perform? (Check all that apply):

Going to work

Exercising

Performing household chores

Doing yard work or shopping

Socializing with friends

Participating in recreational activities

Relieving and aggravating factors

How do the following affects your pain (check one of each item)

LAYING DOWN

Decrease

No change

Increase

STANDING

Decrease

No change

Increase

SITTING

Decrease

No change

Increase

WALKING

Decrease

No change

Increase

EXERCISE

Decrease

No change

Increase

RELAXATION

Decrease

No change

Increase

BENDING

Decrease

No change

Increase

DRIVING/RIDING

Decrease

No change

Increase

BOWEL MOVEMENTS

Decrease

No change

Increase

Previous Pain Treatment

(Check all that apply):

Surgery

Heat Treatment

Psychotherapy

Alternate Medicine / Herbal therapy

Nerve Block / Injection

Cold / Ice Treatment

Chiropractic Manipulation

Physical Therapy

Oral / Topical Medication

Bracing / Traction

Exercise

TENS

Biofeedback

Massage

Acupuncture

Others

If Other, Please specify:

PRIOR PAIN MEDICATIONS: Please check ALL medications you have ever used in the past for treatment.

Opioids

Hydrocodone / Vicodin / Norco

Propoxyphene / Darvocet

Fentanyl

Hydromorphone / Dilaudid

Morphine / MS Contin

Meperidine / Demerol

Levorphanol / Levo Dromoran

Methadone

Oxycodone / Percocet

OxyContin

Tramadol / Ultram

Tapentadol / Nucynta

Oxymorphone / Opana

Buprenorphine / Butrans

Suboxone / Belbuca

Butorphanol / Stadol

Pentazocine / Talwin

Nalbuphine / Nubain

MUSCLE RELAXERS

Baclofen / Ozobax

Carisoprodol / Soma

Cyclobenzaprine / Flexeril

Amrix

Methocarbamol / Robaxin

Metaxalone / Skelaxin

Chlorzoxazone / Lorzone

Parafon Forte

Orphenadrine

Tizanidine / Zanaflex

Dantrolene / Dantrium

None of the above

NSAIDs / Tylenol

Acetaminophen / Tylenol

Aspirin

Ibuprofen / Motrin

Naproxen / Aleve / Anaprox

Etodolac / Lodine

Indomethacin / Indocin

Ketoprofen

Nabumetone / Relafen

Piroxicam / Feldene

Celecoxib / Celebrex

Diclofenac / Votaren

Oxaprozin / Daypro

Ketorolac / Toradol

Meloxicam / Mobic

Vioxx

Salsalate / Trilisate

Sulindac / Clinoril

Tolmetin

Meclofenamate

Flurbiprofen / Ansaid

Mefenamic acid/ Ponstel

Fenoprofen / Nalfon

Arthrotec

Cataflam

NEUROLEPTICS / NERVE PAIN

Gabapentin / Neurontin

Horizant

Pregabalin / Lyrica

Carbamazepine

Milnacipran / Savella

Oxcarbazepine

None of the above

Anti-Depressants/ Anti-Anxiety

Trifluoperazine / Stelazine

Risperidone / Risperdal

Olanzapine / Zyprexa

Ziprasidone / Geodon

Quetiapine / Seroquel

Lurasidone / Latuda

Fluoxetine / Prozac

Escitalopram / Lexapro

Sertraline / Zoloft

Citalopram / Celexa

Venlafaxine / Effexor

Bupropion / Wellbutrin

Paroxetine / Paxil

Vortioxetine / Trintellix

Clonazepam / Klonopin

Diazepam / Valium

Chlordiazepoxide / Librium

Lorazepam / ativan

Temazepam / Restoril

Alprazolam / Xanax

Hydroxyzine / Vistaril / Atarax

Buspirone / BuSpar

Doxepin

Trazodone / Oleptro

Maprotiline

Aripiprazole / Abilify

Desvenlafaxine / Pristiq

Amitriptyline / Elavil

Desvenlafaxine / Pristiq

Duloxetine / Cymbalta

Nortriptyline / Pamelor

Imipramine / Tofranil

None of the above

1. Are you currently being treated for any medical condition or have you been treated within the past year?

YesNoNot Sure / Maybe

If yes, please explain:

2. When was your last medical checkup?

3. Has there been any change in your general health in the past year?

YesNoNot Sure / Maybe

If yes, please explain:

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

YesNoNot Sure / Maybe

If yes, please list them:

5. Do you have any allergies? (If yes, please list them using the categories below)

YesNoNot Sure / Maybe

A) Medications

B) Latex/ Rubber Products

C) Others

6. Have you ever had a peculiar or adverse reaction to any medicines or injections?

YesNo

If yes, please explain:

7. Do you have or have you ever had asthma?

YesNoNot Sure / Maybe

8. Do you have or have you ever had any heart or blood pressure problems?

YesNoNot Sure / Maybe

9. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant?

YesNoNot Sure / Maybe

10. Do you have a prosthetic or artificial joint?

YesNoNot Sure / Maybe

11. Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?

YesNo Not Sure / Maybe

12. Have you ever had hepatitis, jaundice or liver disease?

YesNoNot Sure / Maybe

13. Do you have a bleeding problem or bleeding disorder?

YesNoNot Sure / Maybe

14. Have you ever been hospitalized for any illnesses or operations?

YesNoNot Sure / Maybe

If yes, please explain:

15. Do you have or have you ever had any of the following? (Please check all that apply):

Chest pain, angina

Rheumatic fever

Pacemaker

Steroid Therapy

Seizures (epilepsy)

Heart attack

Mitral valve prolapse

Lung disease

Diabetes

Kidney disease

Stroke TIA

Tuberculosis

Stomach ulcers

Thyroid disease

Shortness of breath

Heart murmur

Cancer

arthritis

Drug/alcohol/cannabis use or dependency

Osteoporosis medications (e.g Fosamax, Actonel)

None of these

16. Are there any conditions or diseases not listed above that you have or have had?

YesNoNot Sure / Maybe

If yes, please explain:

17. Are there any diseases or medical problems that run in your family (e.g. diabetes, cancer or heart disease)?

YesNoNot Sure / Maybe

If yes, please explain:

18. Do you smoke or chew tobacco products?

YesNoNot Sure / Maybe

19. Are you nervous during dental treatment?

YesNoNot Sure / Maybe

20. Are you breastfeeding or pregnant?

YesNoNot Sure / Maybe

If pregnant, what is the expected delivery date?:

21. Do you identify as a patient with a disability?

YesNoNot Sure / Maybe

If yes, please explain.

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